High patient ratio-that's just the way it is...

I'm a nurse who is 5 years out now. I've been in tele/med/surg, home care, long term care and cardiopulmonary stepdown...yeah, been looking for my "niche". I started late in nursing and it's a second career for me. I'm 43. 'Nuff background...

I've gone back to tele/med-surg now, at a small, rural, community hospital. During the interview I was told sometimes patio ratios could get as high as 1-7, but that wasn't most of the time. I kind of looked surprised, but I needed the job. My home health gig was over because my grandparents I'd been caring for had to enter a nursing home. There are not many jobs in our rural community, so I had to take what I could find. Finances, ya know.

Six weeks of orientation offered, and I'm in week 4 now. I have had my doubts and reservations all during the process but just tried to stick things out and believe that in time it would be better as I got used to things. I'm not so sure. My preceptor and I have regularly had 7-9 patients to deal with, and so have the other nurses on the floor. Many times they do not have enough techs, or a tech is pulled to another floor and so the nurse has to do primary care. They do usually drop that nurse's patient load to 5-6 when she has to do that job as well as her own, but STILL.

This is a tele floor with no monitor watcher! Most of the nurses cannot read rhythms. They have ICU as backup to watch our monitor. The computer system is confused, since they are trying to go "all electronic" and some doctors resist this, they are still going back and forth between a lot of chart stuff and some computer stuff. Protocols are sketchy-many times no one seems to know who is supposed to do what (who transfers orders when a patient comes back from surgery?), you don't have a charge nurse or unit secretary on the weekends so you do all of their work too (and being new, I'm lucky to understand what the heck the NURSE is supposed to be doing in this place).

Bedside nursing has never been something I enjoyed, but I recognized it as a valuable tool to learn a lot, and it's really the only job op I have right now. Many of my other nursing friends who are still in large hospitals are telling me that seeing my coworkers crying in the breakroom due to the patient load is a sign to me that it's a bad work environment and I should get out.

In two weeks, yes, right as I get out of orientation, we are moving to our new hospital that they just built. Management said they had "high hopes" of our floor becoming more of a stepdown unit once we get settled at the new facility, where we are ACLS certified, titrate meds, and get a monitor watcher. That's great, but they also said they wanted to see us have a max of 6 patients there. That would be more than we should have, in my opinion, if we are doing all those other skills...however, the new schedule came out and it plainly shows our manager is not scheduling to have enough nurses for us to have 6 patients. So, same old same old...they are going to require us to become more highly certified, have higher acuity patients and more duties, and still have 7-9 patients.

I'm not comfortable with this, but I don't know what to do! I hate the idea of having gone through my orientation and then just going and finding another job! I mean, that will look like crap on my resume, and make it harder on the other nurses on the floor because my leaving with cause them to have to train someone else new for 6 weeks. I have been working in different settings since I graduated, trying to find the right place for me...I've never stayed anywhere longer than 1.5 years. If I leave, I'll have to explain in interviews why I went through orientation at a hospital only to seek another job.

Financially I had to take this job, we couldn't wait any longer for me to find something because we were sinking. But I feel I may have made a mistake. Maybe I will just have to tough it out for awhile, but I was really hoping to find someplace where I could put my feet down and STAY so my resume wasn't so jumpy. It seems I'm looking for another setting every year or so.

I don't know...I'm worried about the patient acuity/ratio and potential dangers...

You are not alone, I now have 17 years of LTC/sub acute experience and after 4 years of it initially I found that I had to seek other avenues to improve myself. I didnt succeed. I was stuck doing a job that repeatedly injured me and made me depressed. I wanted to voyage out and onward thinking I can improve my chances of landing a job that was new and challenging. It didnt happen. Now I am 56 and are just about giving up. I want an office job, I even applied for medical assistant jobs hoping that I can(through the office) get other certifications while I worked. I am overqualified THEY SAY...overqualified????? How is that? If a person is intensely willing and able to perform and improve oneself why wouldnt anyone out there give you a break.????? I find this humilating and discouraging. Being a new nurse is even tougher, you start wondering what did I do? Why did I put myself all through this only to not be able to find work.
I wouldnt stop myself from bettering myself....if you think of it all down the line, this is your decision and your life...no one will be there to hoist your butt out of a bad nursing job or something that you feel that you can do to get yourself a better posiiton. Unless an angel drops down from heaven above and walks you into a new job, this is the only way.
You are having second thoughts. you feel guilty now and its unstandable. But its a dog eat dog world out there now with the economy and all and you just have to be a little more self centered now with the help of God you will pull through and determine what is best for you down the line. I have seen Directors of Nursing come into faciltiies and bring their families and friends in to work at the same place....only to find that they werent satisfied and QUIT...to leave the nurses/staff/patients left high and dry without adequate staff. This is very extreme and should be stopped. Its downright evil when these nurses do such a thing, but it happens. Think before you leap and I am sure you will get the right answer to tell you what to do. I wish you the best of luck.

Feb 10, '13

You only have one license. You can find another job.

I have long thought that if I were in your situation I would quit and then stand in a public place with a sign stating "This hospital is understaffed and NOT safe"

It doesn't have to be the way it is.

Sure I'd look for another job. Lots of employers like to hire nurses.

Feb 10, '13

Lots of employers like to hire nurses? Like employers that aren't healthcare employers?? I figured I am pigeon-holed in healthcare.

Feb 10, '13

I would work in day care, babysit, do private duty in a home with housework included, or work in a store rather than work with such unsafe rastios my license was at risk.
I haven't had to since being licened but would have.

Feb 10, '13

Step down is NOT 6 pts and not 6 pts on gtts. Step down has been 4 pts tops in both facilities I worked. They are still fragile and need close monitoring. That is crazy.. I would run.

7-9 pts, little to no techs, no charge on the weekends or a unit secretary.. Wow

Feb 10, '13

Yeah, that's kind of what I thought...but I didn't want to give up on this too easily. Stepdown was four patients in the cardiostepdown I worked in before, too. I can't see how they can ask us to deal with drips on people right from the ICU and give us that many to care for. I'm very worried...

Feb 13, '13

OK - for sure the OP is in a pickle. My comments are based on the assumption that this is not a unionized environment.

First - get yourself a personal liability policy.

Then, investigate to see if your state BON has a 'safe harbor' type process. In TX, this is the formal process that a nurse can use when s/he believes that the assignment is unsafe and could result in a breech of patient safety. The nurse fills out and files this form - facility must follow up appropriately (there is a step by step process). The most important thing - IF something happens, that nurse is pretty much protected from personal liability from things that occurred due to the problem that was identified... not for lapses in judgement, carelessness, etc. If the OPs state does not have this type of process . . .

Talk to your manager - outlining all of your concerns in a very objective way. Tell her of specific things that have happened, including 'near misses'. Let her know that you are extremely concerned about the impact of staffing on patient safety. Be sure to tell her that you will be looking for work elsewhere rather then jeopardize your job or willingly work in an unsafe manner. Offer to help her with any corrective actions that she can figure out... this may mean scheduling everyone to work at least one OT shift per pay period or something. DO NOT try a 'petition' type approach or other group-based initiative. If you are not in a union environment, this will be interpreted as an effort to initiate an organized labor movement.

Begin keeping a personal record of all issues and problems that happen due to low staffing along with the nurse-patient ratio for that shift: 'near misses', errors, patient care lapses, family dissatisfaction, etc. Do not include any patient identifiers. Formally report any 'near misses' and errors that occur - using the facility's normal processes. REPORT EVERYTHING. The higher-ups and Risk Management / Quality may not know what is going on because your manager may be stonewalling problems so that she gets kudos (bonus?) for running on such a lean labor budget. When the incident reports start poring in, this will change.

If you get no appropriate response from your manager, take it up the ladder. Talk to HR. Talk to the DON. But be very professional and objective, referring to your own records as needed. At this point, you need to accept the fact that you may need to leave this job. If you do leave, you need to consider reporting the situation to your state's hospital licensing agency and CMS.

Best of luck to you.

Feb 20, '13

I wouldn't worry about the step down unit thing until it actually happens. Maybe they would increase staffing at that time when it actually happens. Do you work night shift or day shift? I do not think 7-9 patients is all that uncommon for that shift.

Feb 21, '13

I'm day shift, and since I lost posted, things are getting a little better, but not much. We are moving to our new facility on Saturday. I have been told by the manager that there will be a unit secretary on the weekends, too...and instead of leaving at 5, they will stay until 8. That's good. They are making efforts to limit our patient load to 6, but no one even attempts to promise that's going to hold.

As far as the idea that I report any near misses due to low staffing, I would never be aware of anyone else's near miss. People are very tight lipped about that. I would only know about my own. From what I can see, the nurses have simply adapted to the situation, but are very unhappy about it. I tried speaking to my manager about the situation, but received the brush-off. We get regular "We can deal with any situation, we are NURSES" kind of YADDA YADDA routines to keep everyone feeling like they are somehow disloyal to nursing or their patients if they complain at all. It takes very little to be interpreted as "complaining" or "being negative"...and it is strongly frowned upon. Brother...and yes, I do think there have been worries over the possibility of a union forming, based on what some other nurses have told me.

I have already begun looking for other work, and I haven't even gotten out of orientation yet. If I find something that I feel is a better situation, I will give my two weeks and explain that a large part of it is the staffing issues. I don't think the situation will ever change, and most nurses there seem to feel it's some kind of "badge of courage" to have made it through, so they don't try to effect much change.

There are good things about the job, and bad things as well...the bad things are winning right now.

Thanks everyone....

Mar 15, '13

Well, after moving to the new facility, the crapola hit the fan. I wish I had just listened to my gut and left during orientation. That would have been easier to explain later.

In the new hospital, they had placed so much new technology they hadn't tested that it was a nightmare! Our Iphones don't work and don't hold a charge the whole shift, the computers were having problems, due to the new phone system the fax machines only work half the time and they rely on them for their admission and discharge processes, the phone number list is updated every 2-3 days-which keeps things confusing, and they haven't even rolled out all their "exciting" new features yet. The staff are stressed, frustrated, and OHHHHH, guess what? The six patients per nurse promise was a sham right from the beginning. We are regularly getting 7-8 patients, and our techs are getting 10. The call lights are going off constantly, the techs are nowhere to be found (often we have a full floor of 25 pt with only two techs, so each of them gets ten patients and a nurse ends up doing her own teching for five...)

People are exhausted and miserable, fighting the great technology and trying to pass all the pills, get all the documentation done, half the time teching for themselves, trying to contact doctors who refuse to leave progress notes or check in with nurses so they know what's going on...the communication breakdown in the hospital is staggering.

Each shift I work I make errors, small and correctable ordinarily, but I am constantly fighting the urge to cry (like that will help me) or have a panic attack (also not helpful). The feeling that I am drowning is constant, and most often I do not get a lunch because there is no time to manage that. I'm lucky to stay hydrated. The only way we survive is our charge nurse and our unit secretary run from pod to pod (that's what they call our nursing sections...) and try to do our discharges and admissions for us. Their workload is staggering as well.

Finally, after being offered work at a local nursing home, I gave my notice. I sat down with my manager and told her frankly why things were not working, that I had hoped things would get better when I was out of orientation but they have only gotten worse. We talked about the staffing issues, which she readily agreed were a problem (!) and the problems with the technology not working well and how much harder it made the work day. We talked about being given 7 patients or more to deal with, and they were on tele ruling out CP, post surgical, unstable cardiac issues, total hips, on PCAs, Bumex drips, etc, and how sometimes the tech was so bombarded the nurse was doing it all. We talked about it all, and she asked me if I would stay anyway. I told her there was no way I could do that. She promised staffing will get better, but many things she had no way of promising they would improve.

In truth, my nerves are shot and I am sick before every shift. I mean stressed and sick to the point of crying and trembling. I have begun to suffer chronic migraines.

So here comes the part I will probably get picked on for, but I honestly felt I had no other choice:

I only made it through three shifts of my two-week notice before yesterday happened. I walked in to 7 patients and the zoo that usually ensues. I had a doctor scream at me for not answering a phone that was ringing in the pod when I was trying to pause and get my notes straight and wasn't even HEARING the phone, I was keeping my head barely above water all day, taking until nearly noon to pass AM meds (and I NEVER stopped, not once...I am not the kind of nurse who stands about talking about what they did over the weekend and giggling for a half hour, and then exclaiming that I have no time to finish my work. I NEVER STOP because I am desperately trying to get every detail finished so I can get the heck out on time). It was, as usual, a terrible, suffocating day where I feel my patients aren't getting adequate care, I hardly know anything about any of them but am expected to converse intelligently about them and know every detail about their issues, I am getting their rooms and names confused when talking about them...oh, it's impossible to explain it all. There is so much that goes into every moment in a 12 hour shift that is just overburdened like that.

Anyway, around 8pm when I was finally finished with documenting, reporting, a bit of wound care I'd forgotten to do, etc. etc. I walked into the breakroom and realized I never want to do that again...that I COULD NOT do it anymore. I felt my license and my sanity were truly at risk. I sat down and jotted a note to my manager, telling her I felt the staffing was too unsafe to continue in this manner any longer, and that I would not be returning for the second week of my two week notice.

I popped my badge off, and since my manager was gone for the day, I slid my badge and note under her door.

In a job-unrelated, but relevant to my emotional health sidenote: I checked my personal phone and found out that my grandfather-who was the man I called father and raised me-had died yesterday afternoon. I believe I drove home in a fog after that.

When I got home, my family was crying and broken about my grandfather. I called in to the supervisor and told her I would not be in to work today due to a death in the family. But I also sent a follow-up email to my manager to tell her I would not be coming back next week, and why.

Having noticed that my manager is going to be off for a few days on the schedule I have at home, I sent another email to the charge nurse to tell her I will not be back next week. Hell, I may call the staffing manager tonight and let her know, too, just so no one will be able to say they didn't get the emails and I did a "no-call-no-show". I want them to be able to have as much time as possible to get someone to take my shifts. But I simply COULD NOT GO BACK.

Yes, I know that is not the most professional thing I could have done. Yes, I know this will result in a "will not rehire" situation. It is unsafe, and I am tired of ruining my health being sick over it.

Currently I am still hired at the nursing home and going to orientation next week. I don't know if they will call my ex-current job to ask anything. I had explained to them in the interview at the nursing home that I was leaving due to staffing problems and technology the hospital doesn't seem to be able to make work well, and that I wanted the calmer pace (ordinarily) of a LTC facility and to be able to connect with the patients better. This is all very true. They don't know I didn't work out the last two weeks at the hospital due to safety concerns, though. Don't know if I should bring that up or just move on.

All I can say is that this ended badly. I am getting 8 hour shifts in this new job, probably some rough staffing issues like most LTC...but still nothing like the continuous panicky situations in acute care I just left. In the future I will listen to my gut and stop worrying what others will think. It would have saved me a lot of heartache if I had.

OK -
. The higher-ups and Risk Management / Quality may not know what is going on because your manager may be stonewalling problems so that she gets kudos (bonus?) for running on such a lean labor budget. When the incident reports start poring in, this will change.

If you get no appropriate response from your manager, take it up the ladder. Talk to HR. Talk to the DON. But be very professional and objective, referring to your own records as needed. At this point, you need to accept the fact that you may need to leave this job. If you do leave, you need to consider reporting the situation to your state's hospital licensing agency and CMS.

Best of luck to you.

I was told by other coworkers that there is indeed a bonus because she runs her staffing so lean. It's hard to imagine offering such a thing, when the consequences are so high. Recently there have been several complaints from patients that they are not satisfied with their care. As to how many incidents there have been, I can't say. Our floor is so spread out now that we work in PODS that we barely know other nurses are around unless we walk quite a ways to find them. I have no idea what is happening with the rest of the staff...just my own situation.

In my exit interview paperwork, I wrote down exactly why I was leaving and it asked for suggestions on how to make the hospital better. I gave plenty of them. So HR is aware. I have also been told I am the third nurse to leave shortly after orientation for these same reasons, in less than a year. Who knows if they will pay any attention? They are so hyped up on their new hospital and all its dysfunctional new equipment, I don't think they listen to anything. They are still staffing the same way as always and people are miserable at work. When they talk to the manager, she tells them to ONLY talk to her, because she says their opinions are TOXIC. Read my post above explaining how it all ended. I guess I am no longer toxic...but what I was most worried about was being toxic to myself and possibly causing harm to my patients.

Mar 15, '13

I could cry. This is just insanity. When I was a new nurse, my nurse manager took such good care of me. What is happening to the new nurses is simply criminal. This is just making me want to start 'my' union that much more. Just a word of warning. I had patient safety concerns about the hospital I worked in, worked my way up the ladder and finally to the BON. I was fired. I am a whistleblower and I had to sue the hospital. The states BON did not support me saying that it was not within their jurisdiction. Imagine? Be very careful since you are still new. They will chew you up. I'm an old seasoned nurse so I can handle these evil new breed of management. Mention the word union and they start crying. All of the safety violations and labor law violations are illegal and they are losing federal funding because of the lack of quality of care. It'll get better I hope but its going to be a fight. Be careful and complaints must be done anonymously or you'll be made miserable. Trust me, I know.